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2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Biopsy revealed an epidermis with acanthosis and isolated apoptotic keratinocytes&#44; band-like inflammatory infiltrate&#44; and basal vacuolar damage&#46; Well-defined granulomas consisting of histiocytes and lymphocytes were observed in the reticular dermis and hypodermis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; Giemsa&#44; periodic acid-Schiff&#44; and Grocott silver staining were negative for microorganisms&#46; Fite-Faraco staining revealed the presence of acid-alcohol resistant bacilli &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Culture of the biopsy material in L&#246;wenstein-Jensen medium resulted in positive growth after 20 days&#44; and <span class="elsevierStyleItalic">Mycobacterium marinum</span> was subsequently isolated by matrix-assisted laser desorption&#47;ionization time-of-flight mass spectrometry &#40;MALDI-TOF MS&#41;&#44; enabling definitive diagnosis&#46; The patient was diagnosed with a localized skin infection caused by <span class="elsevierStyleItalic">M marinum</span>&#44; with a non-lymphocutaneous distribution&#46; Antibiotic susceptibility testing showed that the microorganism was sensitive to kanamycin &#40;high load&#41;&#44; rifampin&#44; ethambutol&#44; ethionamide&#44; cycloserine&#44; and capreomycin&#44; and was resistant to streptomycin&#44; isoniazid&#44; pyrazinamide&#44; and paraaminosalicylic acid&#46; The patient was initially prescribed minocycline &#40;100&#8239; mg&#47;12&#8239; h&#41;&#46; After 2 months of treatment a marked improvement in the lesions was observed&#46; However&#44; because some active lesions persisted&#44; antibiotic treatment was switched from minocycline to clarithromycin &#40;500&#8239; mg&#47;12&#8239; h&#41;&#46; After another 2 months of treatment&#44; the only remaining lesions were brownish macules&#44; and antibiotic treatment was permanently discontinued&#46; The patient experienced no subsequent recurrence after 6 months of follow-up&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Mycobacterial species other than those of the <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> complex and <span class="elsevierStyleItalic">Mycobacterium leprae</span> are known as nontuberculous mycobacteria&#46; The incidence of infections caused by these mycobacteria is increasing dramatically&#44; mainly due to the prevalence of AIDS and the use of immunosuppressive therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The use of tumor necrosis factor inhibitors is associated with an increased risk of tuberculosis and of infection caused by nontuberculous mycobacteria&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The infection caused by <span class="elsevierStyleItalic">M marinum</span> is historically known as swimming pool or fish tank granuloma&#44; owing to the wide distribution of this microorganism in aquatic environments&#44; especially in stagnant water such as that found in fish ponds or swimming pools not treated with chlorine&#46; The skin infection is acquired by contact with <span class="elsevierStyleItalic">M marinum</span>-contaminated water or with marine animals such as fish or crustaceans&#44; and requires an entry site &#40;usually minor skin trauma&#44; which can be pre-existing or can coincide with exposure to the microorganism&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most common clinical presentation is nodular &#40;60&#37; of cases&#41;&#44; consisting of a single lesion at the inoculation site&#44; usually affecting the upper extremities&#46; Multiple nodular lesions occur in 35&#37; of cases&#44; and are generally arranged linearly following a lymphatic path from the point of inoculation&#44; producing a classical sporotrichoid or lymphocutaneous pattern&#46; Disseminated infections have also been described in several immunocompromised patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis is confirmed by culture of biopsy material&#46; <span class="elsevierStyleItalic">M marinum</span> colonies are normally detected after 10 to 28 days of incubation&#44; although cultures should be monitored for at least 6 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In one study&#44; only a third of acid-fast-stained samples were positive&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A reasonable therapeutic strategy is to prescribe 2 active agents for up to 1 or 2 months after resolution of clinical signs &#40;usually 3 or 4 months in total&#41;&#46; For most patients&#44; clarithromycin and ethambutol tend to provide an optimal balance of efficacy and tolerance&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A search of the literature reveals 7 other cases of <span class="elsevierStyleItalic">M marinum</span> infection in patients receiving treatment with adalimumab for different diseases&#58; rheumatoid arthritis &#40;2&#41;&#44; psoriasis &#40;2&#41;&#44; Crohn&#39;s disease &#40;1&#41;&#44; psoriatic arthritis &#40;1&#41;&#44; and ankylosing spondylitis &#40;1&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion&#44; we present a case of <span class="elsevierStyleItalic">M marinum</span> infection with an atypical clinical presentation&#46; This case underscores the risk of infection by nontuberculous mycobacteria in patients being treated with TNF inhibitors&#44; and the importance of suspecting these infections&#44; especially in individuals with a compatible exposure history&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Mycobacterium marinum Infection in a Woman Taking Adalimumab
Infección por Mycobacterium marinum en una paciente en tratamiento con adalimumab
L. Peña Merino
Autor para correspondencia
lander_merino@hotmail.com

Corresponding author.
, M. Mendieta-Eckert, I. Méndez Maestro, J. Gardeazabal García
Servicio de Dermatología, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 54-year-old woman who was being treated with subcutaneous adalimumab &#40;40&#8239; mg&#47;2 wk&#41; for 1&#8239; year for rheumatoid arthritis was seen for a pruritic rash on her left hand&#46; The rash had appeared 10 days earlier after she cut the third finger of the left hand while preparing fish in her workplace&#46; The patient reported no previous contact with standing water &#40;e&#46;g&#46; aquariums&#44; ponds&#41;&#46; Physical examination revealed multiple erythematous-violaceous papules of 3&#8211;4&#8239; mm on the dorsal aspect &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and palm of the left hand and on the wrist &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; An erosion on the palmar aspect of the third finger of the same hand was identified by the patient as the initial injury &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Biopsy revealed an epidermis with acanthosis and isolated apoptotic keratinocytes&#44; band-like inflammatory infiltrate&#44; and basal vacuolar damage&#46; Well-defined granulomas consisting of histiocytes and lymphocytes were observed in the reticular dermis and hypodermis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; Giemsa&#44; periodic acid-Schiff&#44; and Grocott silver staining were negative for microorganisms&#46; Fite-Faraco staining revealed the presence of acid-alcohol resistant bacilli &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Culture of the biopsy material in L&#246;wenstein-Jensen medium resulted in positive growth after 20 days&#44; and <span class="elsevierStyleItalic">Mycobacterium marinum</span> was subsequently isolated by matrix-assisted laser desorption&#47;ionization time-of-flight mass spectrometry &#40;MALDI-TOF MS&#41;&#44; enabling definitive diagnosis&#46; The patient was diagnosed with a localized skin infection caused by <span class="elsevierStyleItalic">M marinum</span>&#44; with a non-lymphocutaneous distribution&#46; Antibiotic susceptibility testing showed that the microorganism was sensitive to kanamycin &#40;high load&#41;&#44; rifampin&#44; ethambutol&#44; ethionamide&#44; cycloserine&#44; and capreomycin&#44; and was resistant to streptomycin&#44; isoniazid&#44; pyrazinamide&#44; and paraaminosalicylic acid&#46; The patient was initially prescribed minocycline &#40;100&#8239; mg&#47;12&#8239; h&#41;&#46; After 2 months of treatment a marked improvement in the lesions was observed&#46; However&#44; because some active lesions persisted&#44; antibiotic treatment was switched from minocycline to clarithromycin &#40;500&#8239; mg&#47;12&#8239; h&#41;&#46; After another 2 months of treatment&#44; the only remaining lesions were brownish macules&#44; and antibiotic treatment was permanently discontinued&#46; The patient experienced no subsequent recurrence after 6 months of follow-up&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Mycobacterial species other than those of the <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> complex and <span class="elsevierStyleItalic">Mycobacterium leprae</span> are known as nontuberculous mycobacteria&#46; The incidence of infections caused by these mycobacteria is increasing dramatically&#44; mainly due to the prevalence of AIDS and the use of immunosuppressive therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The use of tumor necrosis factor inhibitors is associated with an increased risk of tuberculosis and of infection caused by nontuberculous mycobacteria&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The infection caused by <span class="elsevierStyleItalic">M marinum</span> is historically known as swimming pool or fish tank granuloma&#44; owing to the wide distribution of this microorganism in aquatic environments&#44; especially in stagnant water such as that found in fish ponds or swimming pools not treated with chlorine&#46; The skin infection is acquired by contact with <span class="elsevierStyleItalic">M marinum</span>-contaminated water or with marine animals such as fish or crustaceans&#44; and requires an entry site &#40;usually minor skin trauma&#44; which can be pre-existing or can coincide with exposure to the microorganism&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most common clinical presentation is nodular &#40;60&#37; of cases&#41;&#44; consisting of a single lesion at the inoculation site&#44; usually affecting the upper extremities&#46; Multiple nodular lesions occur in 35&#37; of cases&#44; and are generally arranged linearly following a lymphatic path from the point of inoculation&#44; producing a classical sporotrichoid or lymphocutaneous pattern&#46; Disseminated infections have also been described in several immunocompromised patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis is confirmed by culture of biopsy material&#46; <span class="elsevierStyleItalic">M marinum</span> colonies are normally detected after 10 to 28 days of incubation&#44; although cultures should be monitored for at least 6 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In one study&#44; only a third of acid-fast-stained samples were positive&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A reasonable therapeutic strategy is to prescribe 2 active agents for up to 1 or 2 months after resolution of clinical signs &#40;usually 3 or 4 months in total&#41;&#46; For most patients&#44; clarithromycin and ethambutol tend to provide an optimal balance of efficacy and tolerance&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A search of the literature reveals 7 other cases of <span class="elsevierStyleItalic">M marinum</span> infection in patients receiving treatment with adalimumab for different diseases&#58; 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